Diagnosisand Management of Chronic Open Angle Glaucoma (COAG) in A Palestinian Eye Hospital Diagnosisand Management of Chronic Open Angle Glaucoma (COAG) in A Palestinian Eye Hospital

Volume 7, Issue 8, August – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Diagnosisand Management of Chronic Open Angle

Glaucoma (COAG) in a Palestinian Eye Hospital
Diagnosisand Management of Chronic Open Angle
Glaucoma (COAG) in a Palestinian Eye Hospital
Asmaa Rjoob1*, Anwar Atieh 1
1
Department of Internal Medicine, Al-Quds University, Jerusalem, State of Palestine
Abstract patients and a professional performance. Re-audit should

be designed after one year of implementing the
 Purpose recommended changes and improvements.
To assess adherence patterns to the UK National
Institute of Health and Clinical Keywords:- Primary Chronic Open-Angle Glaucoma,
Excellence(NICE)guidelines on Primary COAG diagnosis Diagnosis, Management, Guidelines, Clinical Audit.
and Management(2017)in glaucoma clinics of a
Palestinian Eye Hospital. I. INTRODUCTION
 Method A glaucoma is a group of diseases that could affect the

The audit was designed on randomly selected 64 retina's optic nerve and ganglion cells, characterized mainly
primary chronic open-angle glaucoma patients from a by progressive, silent nature; patients may remain
glaucoma clinic of the eye hospital-Palestine, who fulfilled asymptomatic until late.1 According toWHO, Glaucoma is
the inclusion criteria. Patients were divided into two the leading cause of irreversible blindness worldwide. 2
groups (New and Follow up groups), then 32 patients were
randomly selected from each group. Data were collected It has been estimated that by 2020; 80 million people
retrospectively from patients' medical records. The main will be affected by Glaucoma, and of those11milion will be
outcome measures were compliance with six of the main bilaterally blind due to Glaucoma. 3,4
NICE guidelines on glaucoma diagnosis and management
(November 2017). Primary Chronic Open Angle Glaucoma COAG is the
most common type of Glaucoma.5 In which disc cupping and
 Results other glaucomatous disc changes develop in the absence of
Glaucoma clinics showed poor adherence to other known causes, follows chronic time course, with or
guidelines regarding obtaining most of the initial without elevated intraocular pressure IOP and with the
assessment investigations (central corneal thickness 0%, evidence of open anterior chamber angle.6 Currently, more
gonioscopy 25%, 44% visual field testing, and optic nerve than 3 million people are bilaterally blind due to primary
image 22%), the choice of initial treatment (41%), chronic open-angle Glaucoma worldwide. It is estimated that
arranging appropriate monitoring intervals (56%), and more than 2 million will develop primary chronic open-angle
whether compliance with treatment was checked (6%). Glaucoma each year.7
However, full adherence (100%) was seen in obtaining
applanation tonometry and disc assessment at the initial The UK National Institute of Health and Clinical
assessment. Excellence (NICE) On November 2017 published its
guidance on the diagnosis and management of Primary
 Conclusion Chronic Open Angle Glaucoma and Ocular Hypertension,
In general, both patient groups’ results show poor intending to provide the best quality of care for those
adherence to NICEguidelines and generalization of the patients.8
clinical practice to most patients with restricted tests and
plans that have been performed and generalized. No clear We conducted this Audit to measure the current practice
or definite local or global guideline is followed in the within the eye hospital team in diagnosing and managing
practice. Therefore, appropriate policy changes and Primary Chronic Open Angle Glaucoma against the
programs to increase awareness of NICE guidelines are recommendations in NICE guidance.
recommended to improve the quality of care for glaucoma
IJISRT22AUG118 www.ijisrt.com 16
ISSN No:-2456-2165
II. MATERIALS AND METHODS People with primary congenital, infantile, or childhood
glaucoma.
A retrospective analysis of 64 Primary Chronic Open Patients with OHT have no clinical evidence of optic nerve
Angle Glaucoma patients' case notes was carried out as the damage or visual field defect.
following: Firstly, we divided the documented cases of People with suspected COAG.
primary COAG on Apex Electronic System of the Hospital
into two groups; the first was the New Patients group which  Standards:
included all the patients who met the inclusion criteria (see Standard1: At diagnosis, patients have:
below), and was diagnosed after 1st of January 2018 . The  Goldmann applanation tonometry
second group was the Follow-Up Patients who met the  Central corneal thickness 
inclusion criteria and was diagnosed before1st of January
2018. Secondly, 32 patients were randomly chosen from each  Gonioscopy
group. Using the NICE guidelines (NG81) published in  Disc assessment
November 2017, we identified six standards for primary  Visual field assessment
COAG, three for each group, and designed a data collection
Standard 2: An optic nerve head image is obtained at
sheet. We then collected data on five occasions from 9 st  to
diagnosis for baseline documentation.
19th of August 2018. Then entered, it into a Microsoft Excel Standard 3: Choice of treatment and drug used follows the
spreadsheet and statistically analyzed it using Microsoft NICE algorithm.
Excel software (2007). Standard 4: At each monitoring visit, patients have Goldmann
tonometry.
 Inclusion criteria: Standard 5: Patients' planned review intervals are set
For the New patients' group: Patients, who are 18 years following the NICE algorithm.
old or more, were diagnosed with   primary COAG after the Standard 6: Patients' adherence to treatment is checked at the
1st of January, 2018. review appointment.
For Follow-up patients’ group: Patients who are 18 III. RESULTS

years old or more, with primary COAG, who were diagnosed
before1st of January 2018 and presented for follow–up visit. Data from 64 patients were collected (32 new and 32
follow-up groups). The results are summarized in Table1 and
 Exclusion criteria: Table 2. There was no significant difference between the
Children and young people under 18 years. mean age of patients in each group; in the new patient group,
People with secondary glaucoma,e.g. neovascular or uveitic the mean age was 60.5 ± 13.8 (mean±SD). The follow-up
glaucoma. group's mean age was 53.0 ± 14.8 (mean±SD).
People with primary or secondary angle closure glaucoma.
Standards (n=32)
Initial assessment
Goldmann applanation tonometry 100%
Central corneal thickness 0%
Gonioscopy 25%
Disc assessment 100%
Visual field assessment 44%
Obtain an optic nerve head image diagnosis for baseline 22%
documentation
Choice of treatment and drug used follow the NICE 41%
algorithm
Table 1:- Adherence to the NICE guidelines in Glaucoma clinics of The Eye Hospital-Palestine (new patient group)
Standards (n=32)
Perform Goldmann tonometry at every reassessment visit 88%
Planned review intervals in accordance with the NICE algorithm 56%
Patient’s adherence to treatment checked 6%
Table 2:- Adherence to the NICE guidelines in Glaucoma clinics of The Eye Hospital-Palestine (Folow-up patients)
ISSN No:-2456-2165
The gender distribution was also similar between the field testing at the time of diagnosis. 8 This afirms the
two groups; in the new patient group, 50% were male. In the significance of performing visual-field testing (perimetry)
follow-up group,44% were male. In standard 1 (initial when the optic nerve appears abnormal, with attention to
assessment), 100% of patients had Goldmann tonometry and glaucomatous visual-field defects.10
disc assessment, 44% had visual fields, 25% had gonioscopy,
and 0% had central corneal thickness assessment. In standard The results from standards 5, which assesses whether
2 (obtaining optic nerve head image), only 22% of cases had patients are followed up at the appropriate time, highlights the
an image. Standard 3 (initial treatment following the NICE importance of following a standardized algorithm to make a
algorithm) has adhered to 41%. Standard 4 (monitoring visit correct reassessment interval for glaucoma patients as only
assessment), applanation tonometry was performed in 88% of 56% of patients were followed up during the appropriate time
patients at their review visit. Standard 5 (patients monitored interval as compared with 92% in the Manchester Royal Eye
according to the NICE algorithm): 56% of patients complied Hospital study (P <0.01).
with this standard. When looking into checking compliance
(standard 6), compliance checked in no more than 6% of NICE has emphasized the importance of checking for
follow-up glaucoma patients. compliance with treatment. However, we found that
compliance was only checked in 6% of our patients as
IV. DISCUSSION compared with 88% in the Manchester Royal Eye Hospital
study (P<0.01). This further supports the value of a complete
Primary open-angle Glaucoma, the most common type pre-designed assessment computerized sheet followed by the
of Glaucoma, is a chronic optic neuropathy often requiring guidelines for glaucoma patients.
lifelong treatment. Patients play a crucial role in improving
outcomes and economic aftermath correlated with disease To our knowledge, this is the first study done in
progression by their compliance, adherence, and persistence Palestine that has compared adherence with the NICE
with therapy. As long as POAG can lead to irreversible guidance on glaucoma management, thus allowing us to
blindness if left untreated, early diagnosis and appropriate identify ways to stress the significance of following clear
management make Glaucoma tractable to therapy, by which guidelines in diagnosing and managing glaucoma best quality
the majority of patients with this condition can retain good of service to our patients.
visual function .9,10,11
V. CONCLUSION
The results of this study showed that most of the
guidelines have a lower adherence rate and significant In general, both patient groups' results show poor
difference (P <0.01) in glaucoma clinics in a Palestinian eye adherence to NICE guidelines and generalization of the
hospital, compared with a similar study done in Manchester clinical practice to most patients with restricted tests and
Royal Eye Hospital. Which to our knowledge, the only plans that have been performed and generalized. In addition,
identical published study compared adherence with the NICE there is no clear or definite local or global guideline followed
guidelines on glaucoma management.12 Both central corneal in the practice. Therefore, appropriate policy changes and
thickness and gonioscopy were done in 96% of Manchester programs to increase awareness of NICE guidelines are
Royal Eye Hospital patients, but 0% of our patients had the recommended to improve the quality of care for glaucoma
central corneal thickness. Only 25% had gonioscopy patients and professional performance. In addition, a re-audit
(P<0.01). In addition, obtaining disc imaging during the should be designed after one year of implementing the
initial visit in 22% of our patients as compared with 94% in recommended changes and improvements.
the Manchester Royal Eye Hospital study (P<0.01).
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Volume 7, Issue 8, August – 2022 International Journal of Innovative Science and Research Technology

Diagnosisand Management of Chronic Open Angle

Abstract patients and a professional performance. Re-audit should

 Method A glaucoma is a group of diseases that could affect the

For Follow-up patients’ group: Patients who are 18 III. RESULTS

[5]. ThamYC, Li X, Wong TY,et al. Global prevalence of

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